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A New Look at Quality of Medical Care in Low-Income Countries

No matter how one looks at it—as differences across nations or as differences within nations—poor people systematically suffer from worse health outcomes than rich people. What role does medical care play?

Numerous studies have documented the role of households in producing good health outcomes—children are healthier when mothers are more educated; rich households are better able to “insure” against health shocks; rich households live in areas with better sanitation and enjoy better nutrition.Based on these studies the explanations for health outcomes among poor people have centered almost exclusively on household choices: either poor people do not use the health system as much as they should or if they do go to doctors it’s usually when it’s too late.

Haji Mirza Hasan Baig, a medical practitioner, waits for business in New Delhi. Photo by Sandeep Kuriakose.

The data for India, however, tell a different story. Adults in rural Rajasthan—a state with one of the worst human development indicators—visit a doctor once a fortnight, a frequency considerably higher than in the United States [1]. In urban India, poor people visit doctors more often than rich people [2]. The same pattern repeats itself in other countries [3]. These results suggest that the medical system also plays a large role in health outcomes.

Earlier studies found no relationship between health outcomes and the presence or absence of a primary health care center, leaving many questions about providers unanswered: Was the lack of a relationship because the doctor was never there? Was the doctor qualified (hold a degree) and competent (knowledgeable)? Did people go to the primary health care center? The data to answer these crucial questions simply didn't exist.

Since 2001, a team of researchers at the World Bank (including myself, Jeffrey Hammer, Paul Gertler), the University of Maryland (Kenneth Leonard), and University of California, Berkeley(Sarah Barber) have been looking at the supply side of health care using new survey techniques to look at the role of the medical system (and medical providers) in determining health outcomes, and to build a set of country case studies. So far we have looked at these questions for Delhi, India and four low- and middle-income countries (Indonesia, Mexico, Paraguay, and Tanzania ).

The Delhi study followed 1,600 individuals over a two-year period (with the Institute of Socio-Economic Research on Development and Democracy). Each individual in the survey was observed close to 50 times during this time.

We documented the identity of the doctors visited by each household and of doctors not visited but were in the neighborhood. A sub-sample of these doctors was tested on what they knew through a series of “vignettes”— questions generated through scenarios of fictitious patients with varying symptoms. We documented all the questions asked, the examinations performed, and the treatments recommended, and we compared them against a “standard-of-practice” measure of “competence” (what you know) compiled by a team of experts.[4] One month after the vignette test was administered we observed doctors in their practices for a day to see whether they actually used their reported knowledge [5].

Overall knowledge of medical practitioners was very low. In four out of five typical cases, the average practitioner was more likely to harm than help. For example, two-thirds gave advice to a woman with pre-eclampsia that would, with high probability, lead to the death of the mother, child, or both.

Households in poor neighborhoods have recourse only to lower quality doctors—and this is the case whether these households see a private or public doctor. The difference in competence between public and private doctors is similar in rich and poor areas.

Competence among doctors in the private and public sector in Delhi is signaled in two ways—doctors with a MBBS degree (equivalent to a M.D. degree in the United States) and those without, but with medical degrees recognized by the government. Private doctors with an MBSS degree are as competent as doctors in the public sector (where all doctors have a MBBS degree), while private doctors without an MBBS degree are far less competent.

Does competence translate into better health care delivery?

We had no prior beliefs before looking at the data, and had heard two types of stories. There was the doctor who was “so good that all he had to do was look in your eyes, and he would know what was wrong” (more competent, poor quality practice) and there was the doctor who “is very good, and what is more, he will read and read if he does not understand your case” (more competent, better quality practice)

This distinction is important for policy. If health-care delivery is poor because doctors are incompetent, the appropriate policy is better training. However if health care is poor, not because doctors are incompetent, but because they do not do much, then better incentives should help [6]. What does the data say?

Medical Practitioners in Delhi, India: Knowledge and PracticeWhat they know (competence):Number of the questions asked and examinations performed in the vignettes for patients presenting with diarrhea or cough.What they did (practice):Number of questions asked and examinations performed in actual practice with patients presenting with diarrhea or cough.Source: "Money for Nothing: The Dire Straits of Medical Practice in India," World Bank Research Working Papers 3669, 2005.

All doctors do less than they say they would do when faced with the same patient. Asked what a doctor would do if a patient came with diarrhea, typical responses would include: “I would ask the patient about vomiting, I would ask about the color of the stool, I would then check for fever….” However, when a patient with diarrhea actually came to the doctor, the doctor would do one-third to one-half of what they had said they would do.

More competent doctors did more. If a doctor knew more, that doctor also asked more questions in practice, so that greater competence also led to better practice. This is good, because it means that training is not wasted. But it also means that poor people have recourse to doctors who are less competent and put in less effort in their practices.

Doctors in the public sector put in far less effort, and spend half the time doing only 60 percent as many examinations as providers in the private sector. Doctors in the public sector applied only 15 percent of what they knew, compared to 50 percent or higher for the private sector doctor. Indeed, the difference in effort between the public and private sector was so stark that people in poor neighborhoods were better-off visiting less-qualified private doctors than more qualified public doctors, at least in terms of diagnostic abilities.

The private sector is not a panacea. Because a private doctor’s practice depends entirely on the volume of patients, their incentives to get patients to come back may be “too strong.” We find that poly-pharmacy (multiple medications, an indicator of “irrationality in prescription” according to the World Health Organization [7]) is far more prevalent among the private doctors.

Can households judge the quality of care they receive?

This part of the study (currently underway) asked our survey households about the doctors in their neighborhood, for the purpose of comparing their valuations of quality with our vignettes-based (and practice-based) definition of quality.

Ifhouseholds cannot judge the competence of doctors, providing more information to them about provider qualification becomes important. This could be done as simply as using visible markers that distinguish types of medical practitioners (for example, posting stickers of different colors outside the offices of doctors with a MBBS degree and outside the offices of those without). The second option is to help households decide when a problem is serious enough to require medical attention and which sort of practitioner would be best (public or private providers).

Policies for improving the quality of medical care in India

Additional training for providers—an oft-advocated policy—is unlikely to improve the quality of service delivery, at least in India. Many doctors know what to do but simply don’t do it, responding to their direct incentives: public doctors are on salary and have very little incentive to provide service and private doctors want repeat business.

Policies to change the image of primary health care in the public sector could improve service delivery, but implementing such policies would require substantial investments. Setting benchmarks of service that people can trust and rely on would be a good start. So would incentives for public doctors to perform at higher levels (perhaps through “bonus” schemes or empowering local authorities to hire and fire).

Findings from India, Indonesia, Mexico, Paraguay, and Tanzania

In all these studies we can think of health outcomes among the poor as an inter-related set of factors:

choice—poor people may have recourse to similar quality care, but make different choices (based on prices or other reasons); and

discrimination—poor people go to the same doctors as rich people but are treated differently.

Using these three processes as criteria for assessing the quality of health care, the case studies reveal notable differences in service quality across the five countries [9]:

Contrary to widespread belief, public doctors are not less competent than private doctors (India, Indonesia, and Tanzania ). In some cases, public doctors are more competent and provide better care than their private sector counterparts (Mexico).

In some countries (India, Mexico, and Tanzania), the public sector does little or nothing to equalize the imbalance in the private sector. In Tanzania and India, patterns in the public sector across rich and poor areas mirror those in the private sector with more competent public doctors locating in richer regions and neighborhoods. In Mexico, the quality in facilities operated by the Ministry of Health is lower in poor areas, but the quality in social security facilities is similar across rich and poor areas.

In Indonesia and Paraguay, the public sector provides equal quality of care for rich and poor people. In Indonesia, this was the result of a stated policy of sending doctors to rural areas; in Paraguay doctors with low bargaining power within the Ministry of Health (and who have to work harder for salary raises) are sent to poorer and more rural areas. In Indonesia between 1993 and 1998 there was a substantial decline in the competence of doctors in the public sector, largely as the result of a hiring freeze.

Inequalities in access are widespread and large, but there is little evidence of inequalities in the active choices that poor and rich people make, or of inequalities in treatment. We are looking at this question in more detail, but the results so far indicate that (a) there is no difference in the choices that poor and rich households make if they have access to the same set of doctors (India) and (b) in Mexico and Paraguay doctors treat rich and poor patients similarly, spending equal time with both, asking as many questions and conducting an equal number of examinations (we do not have the data to look at this issue in India).

The findings, interpretations, and conclusions expressed in this brief are entirely those of the authors. They do not necessarily represent the view of the World Bank, its Executive Directors, or the countries they represent.

JISHNU DAS is an Economist in the Development Research Group (Human Development and Public Services Team). He is interested in the delivery of basic services to households and is currently working on issues relating to the private and public provision of health and education in India and Zambia. *research@worldbank.org

[2] See Jishnu Das and Carolina Sánchez-Páramo,"Short but not Sweet: New Evidence on Short Duration Morbidities from India," Policy Research Working Paper 2971, World Bank, Development Research Group, Washington, D.C., 2003.

[4] The vignettes were designed in consultation with Dr. Tejvir Singh Khurana (University of Pennsylvania) and Dr. Arvind Taneja (Delhi, India). The evaluations of treatments were conducted independently by doctors in two different teams led by Dr. Jonathon Ellen (Johns Hopkins University in Baltimore, Maryland) and by Dr. Zahida khwaja (Lahore, Pakistan).

[5] Jishnu Das and Jeffrey Hammer, "Which Doctor? Combining Vignettes and Item Response to Measure Clinical Competence," Journal of Development Economics (forthcoming), 2005 (based on Policy Research Working Paper3301, 2004); and Jishnu Das and Jeffrey Hammer, "Strained Mercy: The Quality of Medical Care in Delhi," Economic and Political Weekly 39 (9): 951-965, 2004 (based on Policy Research Working Paper3228, 2004).

[6] Jishnu Das and Jeffrey Hammer, "Money for Nothing: The Dire Straits of Medical Practice in India," World Bank Research Working Papers3669, 2005.

[7] WHO Action Program on Essential Drugs and Vaccines, "How to investigate drug use in health facilities: Selected drug use indicators," Geneva, World Health Organization, 1993.